Provider Demographics
NPI:1063074094
Name:DE LA RUA, NICHOLAS MARCEL (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MARCEL
Last Name:DE LA RUA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE STE 542
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3716
Mailing Address - Country:US
Mailing Address - Phone:773-631-2180
Mailing Address - Fax:773-631-5947
Practice Address - Street 1:7447 W TALCOTT AVE STE 542
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3716
Practice Address - Country:US
Practice Address - Phone:773-631-2180
Practice Address - Fax:773-631-5947
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.159353207RC0200X, 207RP1001X
IL125.075168207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease